Valve Repair Surgery Research Articles

Mitral Valve Repair Operations - Aspects of Risk and Uncertainty

About 18 months ago, I received a shock during a routine health examination. I had noises coming from my heart. It was subsequently diagnosed as a (mitral prolapse regurgitation at severity level 3 from 4).

Transesophageal Echocardiography, Mortality, and Length of Hospitalization after Cardiac Valve Surgery

Despite recommendations regarding the use of intraoperative transesophageal echocardiography (TEE), there is no randomized evidence to support its use in cardiac valve surgery. The purpose of this study was to compare the clinical outcomes of patients undergoing open cardiac valve repair or replacement surgery with and without transesophageal echocardiographic monitoring. The hypothesis was that transesophageal echocardiographic monitoring would be associated with lower 30-day mortality and shorter length of hospitalization. In this observational retrospective cohort study, Medicare claims were used to test the association between perioperative TEE and 30-day all-cause mortality and length of hospitalization among patients undergoing open cardiac valve repair or replacement surgery between January 1, 2010, and October 1, 2015. Baseline characteristics were defined by inpatient and outpatient claims. Medicare death records were used to ascertain 30-day mortality. Statistical analyses included regression models and propensity score matching. A total of 219,238 patients underwent open cardiac valve surgery, of whom 85% underwent TEE. Patients who underwent TEE were significantly older and had greater comorbidities. After adjusting for patient demographics, clinical comorbidities, surgical characteristics, and hospital factors, including annual surgical volume, the TEE group had a lower adjusted odds of 30-day mortality (odds ratio, 0.77; 95% CI, 0.73 to 0.82; P<.001), with no difference in length of hospitalization (<0.01%; 95% CI, -0.61% to 0.62%; P=.99). Results were similar across all analyses, including a propensity score-matched cohort. Transesophageal echocardiographic monitoring in cardiac valve repair or replacement surgery was associated with lower 30-day risk-adjusted mortality, without a significant increase in length of hospitalization. These findings support the use of TEE as routine practice in open cardiac valve repair or replacement surgery.

Aortic Valve Repair Compared to Replacement: Starting an Aortic Valve Repair program, is it Worthwhile?

Objective: There is increasing evidence that aortic valve repair surgery leads to better long-term outcomes than valve replacement, although these data mainly come from a few specialized centers an...

Aortic Valve Repair: Baku Experience

Objective: Aortic valve repair could represent an alternative to valve replacement resulting in optimal hemodynamic conditions and avoiding anticoagulation. We analysed our results of aortic valve repair due to leaflets and root pathology. Methods: Between 2004-2019, we operated 74 patients with aortic valve and aortic root disease. Mean age was 49.2±14.7 years. 10 (13.5%) of them were females and 64 (86.5%) males. 18 (24.3%) patients were admitted with isolated aortic valve pathology. 15 (20.3%) patients had urgent operation for type A acute dissection, 14 (18.9%) aortic root aneurysm and 21 pts (28.4%) aortic root and ascending aortic aneurysm. All patients had peri-operative transesophageal echocardiography (TEE). We performed 18 (24.3%) isolated aortic valve repair operations, 38 (51.4%) reimplantation procedures, 16 (21.6%) remodeling procedures and 2 (2.7%) aortic valve repair and extraaortic ring implantation. The spectrum of valve repair techniques included free margin plication, subcomissural annuloplasty, resuspension, autologuos pericardial patch, leaflet replacement, neocomissura, decalsification, and comissurotomy. Results: Post-operative TEE showed trivial or grade I regurgitation for all patients. There were 2 (2.7%) in-hospital deaths (both had David procedure in acute Type A aortic dissection). Mean hospital stay was 8±4 days. Mean follow-up period was 49±11 months. In this period, we lost 1 patient (1.3%). Late echocardiography in the remaining 71 patients revealed mild aortic insufficiency in 66 patients (92.9%), moderate in 4 (5.6%), and moderate-severe in 1 patient (1.4%). Echocardiography confirmed the durability of the valve repair. Conclusions: Aortic valve repair operations, either as an isolated valve repair or in combination with surgery of the root, is an effective procedure with excellent mid-term and long-term outcomes without significant valve-related complications. KEYWORD: e-PD-49 The authors do not declare any conflict of interest.

Combined one-stage minimally invasive surgery for primary pulmonary carcinoma and mitral regurgitation

BackgroundWe report the first successful short-term outcome of one-stage minimally invasive surgery (MIS) mitral valve repair and video-assisted thoracoscopic surgery (VATS) lobectomy.Case presentationWe report the first successful short-term outcome of combined one-stage video-assisted thoracoscopic surgery lobectomy and minimally invasive surgery in a patient with operable primary right upper lobe adenocarcinoma and mitral regurgitation. Post- operative recovery was uneventful, and follow-up at 6 weeks confirmed an excellent surgical and oncologic outcome.ConclusionsWe think one-stage minimally invasive surgery (MIS) cardiac surgery and video-assisted thoracoscopic surgery (VATS) lobectomy would benefit patients with satisfactory cardiac and pulmonary function.

Outcomes of Degenerative Mitral Valve Repair Surgery for Anterior, Posterior, and Bileaflet Pathology

Degenerative mitral valve disease involving anterior leaflet pathology is considered less favorable regarding durability of surgical repair than isolated posterior leaflet disease. We aimed to compare the outcomes of patients undergoing mitral valve repair for anterior, posterior, and bileaflet pathologies, and to investigate predictors for repair failure. Of the 760 consecutive patients with degenerative leaflet disease who underwent mitral valve repair, 485 (64%) had posterior, 223 (29%) had bileaflet, and 52 (7%) had anterior leaflet pathology. Mean age was 58 ± 12, 54 ± 14, and 58 ± 17 years, respectively (P= .001). Mean follow-up was 67 ± 47 months. There was no in-hospital or 30-day mortality. Freedom from reoperation was 97%, 95%, and 92%, respectively, and there were 25 (5%), 9 (4%), and 1 (2%) late deaths in the posterior, bileaflet, and anterior groups, respectively (not significant). Late echocardiography revealed that 94%, 97%, and 96% of patients (posterior, bileaflet, and anterior groups respectively) were free from moderate-severe or severe mitral regurgitation (P= .375). Postoperative residual mild mitral regurgitation emerged as the strongest predictor for recurrent mitral regurgitation (grade 3/4) at follow-up (hazard ratio= 2.36; 95% confidence interval, 1.30-4.29; P= .005). Unlike patients with excess mitral tissue, among patients with fibroelastic deficiency or those who underwent major leaflet resection, the use of larger ring annuloplasty was associated with recurrent mitral regurgitation (hazard ratio= 1.31/ring size increment; P < .001). Mitral valve repair can be achieved with excellent early and intermediate results across all valve pathologies. Further studies are required to determine the potential long-term impact of the underlying pathology on the rate of recurrent mitral regurgitation.

Clinical features and maternal and infant outcomes of right-sided infective endocarditis during pregnancy: a case report and literature review

Objective To investigate the clinical features, treatment strategies, and maternal and infant outcomes of pregnancy complicated by right-sided infective endocarditis (RSIE) to provide evidence for clinical management. Methods By searching literature on RSIE during pregnancy from the databases of CNKI, Wanfang Database, VIP, CBM, PubMed, OVID, EMbase and ScienceDirect, relevant information were collected to analyze the clinical manifestations, risk factors, positions of intracardiac vegetations, results of blood culture, treatment strategies and maternal and infant outcomes of RSIE. Results A total of 15 articles were retrieved, involving 18 infected gravidas with the average age of (27.7±4.8) years and average gestational age at onset of (27.8±6.9) weeks. Fever (n=14), cough (n=12), anemia (n=8) and shortness of breath or dyspnea (n=8) were the common symptoms. Cardiac murmurs were detected on auscultation in seven cases, of which six were systolic murmurs and one was unspecified. Heart sounds of five cases were clear on auscultation without any murmurs. Nine cases were complicated by pulmonary embolism and five by heart failure. The major risk factors were congenital heart diseases (10/18) and intravenous drug abuse (6/18). Vegetations were commonly seen on the tricuspid valves (10/18), followed by the pulmonary valves (4/18). The rate of positive blood culture was high (15/16) with Staphylococcus (9/15) and Streptococcus (3/15) being the primary pathogens. Most pregnancies were timely ended by cesarean section. Apart from receiving fundamental antibiotic therapy for infective endocarditis, 11 patients underwent cardiac surgery, including vegetation removal, valve repair or replacement and surgery for congenital heart diseases, before or after pregnancy or during cesarean section based on their gestational age, condition, and cardiopulmonary function. There was no maternal death, but one neonatal death was reported due to severe asphyxia following cesarean section at 28 weeks. Maternal and neonatal outcomes were good during follow-up. Conclusions Pregnancy complicated by RSIE is rare and complex, requiring early diagnosis and individualized treatment. Adequate and full-course antibiotic therapy, appropriate surgical procedures and timely termination are of great importance for improving maternal and infant outcomes. Key words: Pregnancy complications, cardiovascular; Endocarditis, bacterial; Pregnancy outcome

Relationship between emotional states before cardiac valve surgeries with postoperative complications.

To investigate associations between preoperative anxiety and depression symptoms and postoperative complications and the sociodemographic and clinical characteristics of patients undergoing valve repair surgery. Observational, exploratory and prospective study. The consecutive non-probabilistic sample consisted of patients undergoing their first valve repair surgery. Data were collected from September 2013 to September 2015, in a university hospital in the interior of São Paulo, Brazil. Symptoms were assessed using the Hospital Anxiety and Depression Scale and analyzed using Mann-Whitney and Spearman correlation; alpha was established at 5%. Among the 70 participants, depressive symptoms were more frequent among women (p=0.042) and among patients experiencing postoperative agitation (p=0.039) Conclusion: In this study, depressive symptoms were associated with being a woman and postoperative agitation; the same was not true in regard to anxiety symptoms.

High-sensitivity C-reactive protein as a prognostic marker in patients undergoing valve surgery.

IntroductionAn inflammatory reaction is a local or systemic response of the organs or tissues of the body to many damaging factors. One of the exponents of the inflammatory process is C-reactive protein (CRP).AimTo investigate the prognostic value of C-reactive protein (CRP) in patients undergoing valve surgery.Material and methodsA prospective study was conducted on a group of consecutive patients with haemodynamically significant valve defects who underwent elective valve repair or replacement surgery. The primary end-point was in-hospital death from all causes. Patients were followed by direct observation during hospitalization. The risk of surgery using Euro-SCORE II was calculated for each patient. The plasma levels of C-reactive protein were measured by the Cardiac C-Reactive Protein (Latex) High Sensitive Test (Roche, Germany).ResultsThe study group included 562 patients. The mean age in the studied population was 63 (standard deviation (SD) ±12). The mean plasma preoperative CRP level was 0.39 ±0.3 mg/dl. The primary endpoint occurred in 25 patients. At multivariate analysis age (p = 0.01), CRP (p = 0.02) and NT-proBNP (p = 0.03) remained independent predictors of the primary endpoint. A significant correlation was found between the level of CRP and haemoglobin (r = –0.3; p < 0.0001), red cell distribution width (r = 0.22; p < 0.0001), ejection fraction (r = –0.24, p = 0.007), troponin T (r = 0.3; p < 0.0001), creatinine (r = 0.26; p = 0.001) and body mass index (r = –0.29; p = 0.005). The average total time of hospitalization after the operation in patients with occurrence of the primary endpoint was 25 ±13 days.ConclusionsElevated preoperative CRP was associated with a poorer outcome following valve surgery.

P760 Stress echocardiography testing of a novel trans annular mitral bridge implantation for mitral regurgitation

Abstract Objectives Indirect reduction of septal- lateral diameter (SLD) by circumferential cinching of the annulus with ring annuloplasty (RA) is the standard part of mitral valve repair surgery. Direct SLD reduction without circumferential annular cinching by a novel trans-annular Mitral Bridge with an infra-annular curvature has been used for functional mitral regurgitation (FMR) as a sole procedure and for mitral valve prolapse (MVP)as a part of valve repair. The aim of this study was to assess the functional and hemodynamic outcomes at rest and exercise at 2 yr. follow up in the patients with this novel type of annuloplasty. Methods 30 of 34 patients with FMR who had trans annular Mitral Bridge as the sole treatment of their MR and 5 of 8 patients with MVP in a prospective trial underwent at 2yr F/U bicycle ergometer exercise echocardiography on a special semi-recumbent bicycle. Mitral regurgitation, mitral peak and mean gradient, mitral valve area, systolic pulmonary arterial pressure, systolic function of the left ventricle were assessed at rest and peak exercise. Results Mitral regurgitation was 0.3 ± 0.5 at rest and 0.4 ± 0.5 at peak exercise (p = 0.264). The resting mean mitral gradient was 2.3 ± 0.9 mmHg and peak 4.6 ± 1.9 mmHg (p &amp;lt;.0001) and valve area was at rest 3.5 ± 0.7cm2 and at peak 3.9 ± 0.9 cm2 (p = 0.026). Pulmonary systolic arterial pressure was 25.8 ± 17 at rest and 36.9 ± 21.8 at peak exercise (P = 0.012). LVEF was 60,4± 10.5 at rest and at peak 66,4± 12.5 (p &amp;lt;.0001). Conclusion Trans annular Mitral Bridge as a alternative to standard annuloplasty ring is effective. At 2 yr follow up there was only trace mitral regurgitation and no mitral stenosis. The stress test verified the durability of the mitral repair both in FMR and MVP. There was no mitral stenosis and no mitral regurgitation at exercise. The raise of the mean mitral gradient was statistically important, but the values remained within the normal range. The raise of gradients is in correlation with the presence of cardiac reserve and increased LVEF. There were no signs of pulmonary hypertension caused by the stress. Abstract P760 Figure. Mitral Bridge

P1755 Clinical and echocardiographic outcomes of mitral valve repair surgery

Abstract Background Mitral valve regurgitation (MVR) represents the second most frequent valvular heart disease. MV surgical repair is often the preferred treatment when MV anatomy is suitable. Purpose To characterize the population who underwent MV repair surgery and evaluate the outcomes of residual MVR, allcause mortality and functional classification. Methods Retrospective analysis of 262 patients (P) admitted between 2008 and 2017 for MV repair surgery. P who undergone simultaneous coronary artery bypass graft (CABG) surgery, atrial fibrillation (AF) surgery and tricuspid valve repair were also included. P with endocarditis, P who underwent simultaneous aortic valve replacement and P with rheumatic predominant MV stenosis were excluded, the remaining 204 P were analysed. Clinical and echocardiographic characteristics were evaluated in a mean follow-up of 30 months. Results 204 P, 67.2% male, mean age 62 + 14 years. The most frequent etiology was organic (80.4%), mostly of degenerative cause. Functional etiology was present in 19.6%, mostly ischemic (72.4%). 16.8% underwent simultaneous CABG, 12.3% tricuspid valve repair and 7.8% AF ablation. Hypertension was significantly associated with functional etiology (90% vs 72.8%, p = 0.022), as well as hypercholesterolemia (80% vs 48.2%, p &amp;lt; 0.001) and diabetes mellitus (32.5% vs 10.4%, p &amp;lt; 0.001). Baseline left ventricular ejection fraction (LVEF) was &amp;gt;50% in 78.4%, reduced (30-50%) 18.1% and poor (&amp;lt;30%) in 3.4%. Functional etiology was significantly associated with LVEF &amp;lt;50% (70% vs 9.1%, p &amp;lt; 0.001). 161P (78.9%) had MV prolapse: 120P (74.5%) posterior, 29P (18%) anterior and 7.4% (12P) of both leaflets. P2 was the most frequently involved scallop, in 92P (57.1%), followed by P3, in 41P (25.4%). There was MV chordae rupture in 94P (58.3%). Post-surgery echocardiography revealed that 93.8% had mild or no residual MVR. 30-day mortality rate was 0%. There was MVR recurrence with MV replacement surgery in 15P (7.5%), mean time 37.1 months. All-cause mortality was registered in 28P (13.7%), with a mean time of 43.7 months after MV surgery. Of the P without MVR recurrence or mortality, 111P (70%) were in NYHA class I, 41P (26%) in NYHA class II and 6P (4%) in NYHA class III. 6P were lost to follow-up. Upon echocardiographic revaluation there was no residual MVR in 53P (39%), mild MVR in 67P (49%) and moderate MVR in 16P (11.8%). Conclusion In P who underwent MV repair surgery, there was 7.5% recurrence rate with follow-up MV replacement surgery and an all-cause mortality of 13.7%. In a mean follow-up of 30 months, 70% of P were in NYHA I class and there was none or mild residual MVR in 88% of P.

A roadmap for valve repair surgery

It is well established that mitral valve repair has better outcomes than mitral valve replacement surgery. In the Western world, degenerative mitral valve pathology leading to severe mitral valve regurgitation is the most frequent disease affecting the mitral valve and this pathology is particularly accessible for valve repair. Hence, mitral valve repair is increasingly performed world-wide. However, obstacles may still arise in more complex lesions or minimally invasive approaches.

Aortic valve repair: An evolving space in cardiac surgery

The surgical management of pure aortic regurgitation (AR) continues to evolve and the choice of operation depends on several factors including, the patho-anatomy of the aortic valve and root, patient characteristics and surgical expertise. The absence of an ideal biological or mechanical prosthesis historically stimulated the development of innovative valve-conserving techniques. Early pioneers invented the now established valve sparing aortic root replacement using the remodelling and re-implantation techniques [1,2] which focus on the geometrical correction of the aortic root and restoration of the normal alignment of the aortic valve apparatus to eliminate secondary AR. In the last 10 years or so however, some surgeons have pushed the envelope even further by introducing novel approaches to address primary AR using cusp repair techniques and associated annuloplasty [3-5]. This concept is analogous to more established mitral valve repair techniques which are now refined, reproducible and associated with excellent clinical outcomes. Indeed, it could be said that the current status of aortic valve repair surgery stands where mitral valve repair was some 35 years ago i.e. the preserve of only a hand-full of surgeons working in high-volume centres with a strong innovative ethos.

P1470 Rare cause of papillary muscle rupture post cardiac surgery

Abstract Introduction Papillary muscle rupture (PMR) secondary to mitral valve repair surgery is a rare complication in the postoperative period of cardiac surgery Purpose We present a case of PMR with fatal outcome after mitral valve repair with a rigid ring secondary to accidental ligature of the circumflex artery (CA). Methods An 83-year-old male referred for valvular surgery for symptomatic mitral regurgitation (MR). In the last echocardiography LVEF was mildly depressed (45-50%), severe organic MR (A2 chord rupture), functional TR, and moderate degenerative AR. With these findings and together with a normal coronary angiography, he was presenting at the Heart Team for triple valvular surgery. The procedure consisted of implanting aortic biological prosthesis, mitral and tricuspid annuloplasty. During the pump output, he presented ventricular arrhythmias, but in the intraoperative transesophageal echocardiography (TEE) a good result was demonstrated. At 24h postoperatively the patient enters arrhythmic storm, ischemia data appear on ECG (ST-segment depression of V1-V3 and DI-aVL) and elevation of markers of myocardial damage (TnIc 450 ng/mL), which point to complication postsurgical cardiology is contacted for urgent echocardiography. Results The echocardiography showed a massive MI due to postero-medial PMR, inferior and inferolateral akinesia and severe biventricular dysfunction. With these findings and with the suspicion of accidental ligation of CA during the implantation of the mitral annulus, urgent catheterization is considered. Given the evolution of the ischemic event and the delicate hemodynamic situation, this option is discarded, so that angiographic confirmation is not achieved. Finally, the patient undergoes cardiac revision surgery as a last option. After performing sternotomy, cardiac rupture at a lower level is evidenced, patch closure is attempted but due to tissue friability it is not achieved and the patient dies in the surgical act. Conclusion RMP after mitral valve surgery is a very rare complication. The majority of published cases are related to increased tension forces after mitral replacement with preservation of the subvalvular apparatus. Our case would be the first described of MPR secondary to accidental ligation of AC after mitral annuloplasty.

P1756 Predictors of outcome in mitral valve repair surgery

Abstract Background Surgical mitral valve repair currently remains a good option in both organic or functional mitral valve regurgitation (MVR). However, a significant number of patients (P) have comorbidities that can contribute to adverse outcomes. Objective To determine clinical and echocardiographic predictors of adverse outcomes in P submitted to MV repair surgery in our center, notably MVR recurrence and new MV replacement surgery or all-cause mortality. Methods Retrospective analysis of 262 P who underwent MV repair surgery between 2008 and 2017, with a mean follow-up of 30 months. P were included with both organic or functional MV regurgitation. P who underwent simultaneous coronary artery bypass grafting (CABG), atrial fibrillation (AF) surgery and tricuspid valve repair were also included. However, P with simultaneous surgical aortic valve replacement or previous endocarditis were excluded and the remaining 204 P were analysed. We evaluated whether MVR etiology, simultaneous surgery (tricuspid valve repair, AF or CABG), body mass index (BMI), gender, chronic obstructive pulmonary disease (COPD), diabetes mellitus, renal dysfunction (measured by serum creatinine levels), baseline left ventricular ejection fraction (LVEF) and left ventricle end-diastolic diameter (LVED) were predictors of a composite endpoint (follow-up MV replacement surgery or all-cause mortality) and secondary endpoints: MV replacement surgery and all-cause mortality. Results 204 P who underwent MV repair surgery, 67.2% male, mean age of 62 ± 14 years. 80.4% had organic MVR and 19.6% functional MVR (mostly ischemic – 72.4%). 7P (3.4%) had rheumatic MVR. 16.8% underwent simultaneous CABG, 12.3% tricuspid valve repair and 7.8% AF ablation. 30-day mortality was 0%. The composite endpoint occurred in 40P (20%) and there was MVR recurrence with follow-up MV replacement surgery in 15P (7.5%) and all-cause mortality in 28P (13.7%). The authors found that elevated serum creatinine levels (OR 4.66; p = 0.003), COPD (OR 3.00; p = 0.035) and functional etiology (OR 2.22; p = 0.049) were predictors of the composite endpoint. Both COPD (OR 2.823; p = 0.024) and renal dysfunction (OR 6.901; p = 0.001) were also found to be independent predictors of all-cause mortality. Simultaneous CABG was a predictor of all-cause mortality (OR 2.82; p = 0.024). Female gender was a predictor of future MV replacement surgery (13.4% vs 4.7%, p = 0.023). However, echocardiographic variables (baseline LVEF and LVED) were not found to be significant predictors of adverse outcomes in MV repair surgery. Likewise, simultaneous AF or tricuspid valve surgery, rheumatic/ischemic etiology, high BMI or diabetes were not associated with poorer prognosis. Conclusion In P undergoing MV repair surgery, renal dysfunction and COPD were independent predictors of all-cause mortality. Functional etiology and simultaneous CABG surgery were also predictors of adverse outcomes. Baseline LVEF and LVED were not correlated with prognosis.

Intensive care and anesthesia management for HARPOON beating heart mitral valve repair.

Patients with severe mitral valve regurgitation secondary to degenerative disease are known to benefit from mitral valve repair surgery. Novel techniques for achieving mitral valve repair on the beating heart have been developed and are being introduced into clinical practice. The HARPOON Beating Heart Mitral Valve Repair System (MVRS) in recent studies has demonstrated efficacy and safety for the repair of degenerative mitral valve disease on the beating heart. The device uses transoesophageal echocardiographic guidance to implant artificial expanded polytetrafluoroethylene (ePTFE) cords on prolapsed mitral valve leaflets in the beating heart. It requires general anaesthesia and there are specific intensive care and anaesthesia considerations for the safe management of these cases. This article describes the general principles of intensive care and anaesthesia management employed for the initial patients treated with the HARPOON Beating Heart MVRS, the outcomes for these patients, and the potential challenges for the future management of these cases.

Prognostic factors influencing prolonged ventilation after open mitral valve surgery

Objective: To determine prognostic factors influencing prolonged ventilation after surgery in our hospital. Method: Seventy-five patients fulfilled inclusion criteria were included in this retrospective cross-sectional study. Prognostic factors analyzed were age, chronic pulmonary disease, heart failure (NYHA class function), left ventricular (LV) dysfunction (based on ejection fraction), recent myocardial infarction, pulmonary hypertension (PH), duration of cardiopulmonary bypass (CPB), ischemic time and aorta clamp time, which were analyzed in relation to prolonged ventilation after open mitral valve surgery. Results: Subjects were 75 patients aged between 19 and 62 years old (mean 39.76, SD 11.44) whom underwent open mitral valve repair or replacement surgery. Twenty-three patients (30.67%) had prolonged ventilation (≥24 hours) after surgery. Bivariate analysis showed there were no significant correlation between age, heart failure, PH and LV dysfunction. There are different with statistically significance between groups (p&lt;0.05). Conclusions: In this study, almost one-third of patients had prolonged ventilation after surgery. Factors influencing this morbidity were the duration of ischemic time, aorta clamp time and CPB. Age, heart failure, LV dysfunction and PH were not statistically related to the prolonged ventilation event.

Aortic Root Pressurizing Device: Aortic Valve Evaluation During Cardioplegic Arrest

The aortic root pressurizing device was developed for aortic valve repair surgery. It allows echocardiographic evaluation of the aortic valve during cardioplegic arrest by mimicking diastolic afterload. This polyoxymethylene or polyether ether ketone-based device consists of a sealing cap nut, a sealing ring, a plug screw, and both a filling and a ventilation line. It can be easily connected to any size of aortic Dacron grafts. The device was tested in 15 porcine hearts using a beating heart biosimulator including hemodynamic and echocardiographic monitoring. Valve competence was analyzed on both the beating and resting heart at 60 and 45 mm Hg root pressure. Aortic insufficiency was surgically induced by leaflet manipulation. Native aortic valves showed either none or trivial aortic insufficiency. After leaflet manipulation echocardiographic proof of valve insufficiency was possible in all specimen. Jet direction was identic in all cases at 60 mm Hg and 93% at 45 mm Hg root pressure. The aortic root pressurizing device shows highly comparable results of echocardiographic aortic valve evaluation between static and dynamic settings under experimental conditions.

Myocardial protection technique structured on cardiac mass.

Myocardial protection is crucial in cardiac surgery: quantification is often difficult as there is a significant mismatch between body weight and heart weight as per geometric remodeling. This study has the objective to compare two groups of patients on the administration of myocardial protection in valvular pathologies: the first group has indexed the administration with left ventricular mass index; the second has indexed it on the body weight or on the body surface area. The primary endpoint of double-blind case-control study is to detect the difference in incidence in terms of post-operative low cardiac output syndrome. A single-center double-blind case-control study in a specialized regional tertiary cardiac surgery center in Italy. Between March 2017 and September 2018, 200 adults (100 per Group A vs. Group B) were scheduled for elective procedures: Group A (50 aortic valve replacement-50 mitral valve repair in minimally invasive cardiac surgery) used blood cardioplegic solution with Saint Thomas I solution, with calculation of left ventricular mass index with echocardiographic measures (Formula Group A); Group B (50 aortic valve replacement-50 mitral valve repair in minimally invasive cardiac surgery) used blood cardioplegic solution with Saint Thomas I solution, with calculation indexed on the body surface area, Du Bois Method (Formula Group B). A statistically significant difference was found for Student's t-test in patients who used myocardial indexed protection on left ventricular mass index versus control: aortic valve replacement procedures in aortic valve stenosis-ejection fraction (24 hours, p-value = 0.046), TnT (24 hours, p-value = 0.047), stroke volume shift (24 hours, p-value = 0.043), and infusion of epinephrine after cardiopulmonary bypass (p-value = 0.033); aortic valve replacement procedures in aortic valve insufficiency-ejection fraction (24 hours, p-value = 0.044), TnT (24 hours, p-value = 0.047), stroke volume shift (24 hours, p-value = 0.046), and infusion of Epinephrine after cardiopulmonary bypass (p-value = 0.029). No statistically significant differences in patients undergoing mitral valve repair surgery. The study group in the aortic valve surgery that administered myocardial protection indexed for the left ventricular mass index and showed a statistically significant lower incidence for post-operative low cardiac output syndrome compared to the control group.

Aortic valve repair: state of the art

Mechanical or bioprosthetic aortic valve replacement has traditionally been the treatment of choice for patients with aortic valve insufficiency. However, prosthetic valve replacement has significant limitations being associated with a substantial cumulative risk of thromboembolism, anticoagulation-related hemorrhage, prosthetic valve endocarditis, and structural or non-structural valve dysfunction requiring reoperation. In this setting, aortic valve repair, by avoiding the long-term risks associated with prosthetic valve implantation, has emerged as a valid alternative treatment to conventional aortic valve replacement. In the last decade, improvements in the understanding of the mechanisms of valve disease, development of a classification system for aortic insufficiency and advances in surgical procedures have allowed for more effective and reproducible techniques for aortic valve repair. The aim of the present review is to assess the principles, the surgical techniques, and the role of echocardiographic imaging in the setting of aortic valve repair surgery.